Provider Demographics
NPI:1851572564
Name:EVERGREEN NEUROLOGY & NEURODIAGNOSTIC PLLC
Entity Type:Organization
Organization Name:EVERGREEN NEUROLOGY & NEURODIAGNOSTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-5121
Mailing Address - Street 1:2320 RUCKER AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2723
Mailing Address - Country:US
Mailing Address - Phone:425-259-5121
Mailing Address - Fax:425-252-2189
Practice Address - Street 1:2326 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2723
Practice Address - Country:US
Practice Address - Phone:425-259-5121
Practice Address - Fax:425-252-2189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROMAN L KUTSY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032822204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1118462Medicaid
WA1118462Medicaid
G10879Medicare UPIN